Uma Tupper, L.Ac, MAOM, LMT
Mandala Acupuncture & Bodywork, LLC
925 NW Davis
Portland, OR 97209
503-525-9642
Patient Health History
Name: ______Date: ______/______/______
(first) (middle) (last)
Date of Birth: ______/______/______Age: ___ Gender: M/F Marital status: S M D W
Address: ______
(street) (city/state) (zip code)
Phone Number: (cell)______(work/home)______Best way to contact you:______
Email: ______Blood Type: ______
Primary Care Physician: ______
(name) (phone number)
Emergency Contact:______
(name) (phone number)
**Successful health care and preventative medicine are only possible when the practitioner has a complete
understanding of the patient physically and mentally. Please complete this questionnaire as thoroughly as
possible. Print all information and indicate areas of confusion with a question mark. Thank you.**
- When and where did you last receive health care?
For what reason? ______
2. Please identify the health concerns that have brought you here in order of importance below:
Condition Past Treatment
______
______
How does this condition affect you? ______
3. If applicable, please list any foods, drugs, or medications you are sensitive or allergic to (please include reaction):______
4. Please list any medications (prescribed and over-the-counter), herbs, vitamins, and supplements you are currently taking:
5. Do you have any reason to believe you may be pregnant? Y N
If so, how far along are you? ______
6. Do you have any infectious diseases? Y N If yes, please identify: ______
Name:______Date:______
7. Family History: Father Mother Brothers Sisters Spouse Children
Check those applicable:
Age (if living) ______
Health (G=Good, O=Ok, P=Poor) ______
Cancer ______
Diabetes ______
Heart Disease ______
High Blood Pressure ______
Stroke ______
Mental Illness ______
Asthma/Hay fever/Hives ______
Kidney Disease ______
Age (at death) ______
Cause of Death ______
8. Height: ______Weight: Currently: ______Past Maximum: ______When? ______
9. Blood Pressure: What is your most recent blood pressure reading? ______/______When was this reading taken? ______
10. Childhood Illness (please circle any that you have had):
Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles German Measles Chicken Pox
Other severe illnesses with approximate date: ______
______
11. Hospitalizations and Surgeries:
What Reason When
______
12. X-Rays/CAT Scans/MRI’s/Special Studies:
What Reason When
______
** For the following questions please circle any that you are currently experiencing problems with & and underline any that you have had problems with in the past**
13. Emotional:
Mood Swings Nervousness Stress Depression Anxiety Panic Attacks
Any diagnosedmental illness?______
Currently seeing counselor?Circle one: Y/N______
Currently seeing psychiatrist? Circle one: Y/N
Anything else we should know? ______
______
14. Energy and Immunity:
Fatigue Slow Wound Healing Chronic Infections Chronic Fatigue Syndrome
15. Head, Eye, Ear, Nose, and Throat:
Impaired/Blurry Vision Red/Dry Eyes Poor Night Vision Floaters in Vision
Eye Pain/Strain Glaucoma Glasses/Contacts Tearing/Dryness
Impaired Hearing Ear Ringing Earaches Headaches/Migraines Sinus Problems Nose Bleeds
Frequent Sore Throats Teeth Grinding TMJ/Jaw Problems Hay Fever
Name:______Date:______
16. Respiratory
Pneumonia Frequent Common Colds Difficulty Breathing Emphysema
Persistent Cough Pleurisy Phlegm Asthma
Tuberculosis Shortness of Breath Allergies Chronic Bronchitis
Other Respiratory Problems: ______
17. Cardiovascular:
Heart Disease Chest Pain/Pressure Swelling of Ankles High Blood Pressure
Palpitations/Fluttering Stroke Heart Murmurs Rheumatic Fever Varicose Veins
Abnormal Bleeding Easy Bruising Low Blood Pressure Stroke Heart Attack
18. Gastrointestinal:
Ulcers Changes in Appetite Nausea/Vomiting Very Thirsty No Thirst Epigastric Pain
Passing Gas Heartburn Belching Gall Bladder Disease Liver Disease Hepatitis B or C HemorrhoidsAbdominal Pain Constipation Diarrhea
Any abnormal color, blood, smell, consistency, mucus, frequency, quality or quantity? Y N
If yes please explain: ______
19. Genito-Urinary Tract:
Kidney Disease Painful Urination Frequent UTI Frequent Urination
Kidney Stones Impaired Urination Blood in Urine Frequent Urination at Night
Any abnormal color, smell, urgency, blood, foam, cloudy, frequency, quality or quantity? Y N
If yes please explain: ______
20. Female Reproductive/Breasts:
Irregular Cycles Breast Lumps/Tenderness Nipple Discharge Heavy Flow
Vaginal Discharge/Dryness Premenstrual Problems Clotting Bleeding Between Cycles
Menopausal Symptoms Difficulty Conceiving Painful Periods Sexual Function/Pain
21. Menstrual/Birthing History:
1. Age of First Menses: ______5. Birth Control Type: ______8. # of Abortions: ______
2. # of Days of Menses: ______6. # of Pregnancies: ______9. # of Live Births: ______
3. Length of Cycle: ______7. # of Miscarriages: ______10. Age of Menopause: ______
4. Date of last PAP smear: ______Any abnormalities? ______
22. Male Reproductive:
Sexual Difficulties/Pain Prostate Problems Testicular Pain/Swelling Discharge
23. Musculoskeletal:
Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Upper Back Pain Mid Back Pain
Low Back Pain Leg Pain Joint Pain (if so, where): ______
Any other musculoskeletal issues? ______
24. Neurologic:
Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy
25. Endocrine:
Hypothyroid HypoglycemiaHyperthyroid Diabetes Mellitus Night Sweats Feeling Hot or Cold
26. Dermatologic:
Rash Itching Eczema Psoriasis Acne Herpes I Herpes II Shingles Athlete’s Foot Warts
27. Other (please circle any that you experience now and underline any that you have experienced in the past):
Anemia Cancer Cold Hands/Feet Dry Skin Dry Hair Dry Mouth Dry Eyes Hair Loss
28. Any Chronic or Continuing Illnesses or Conditions? ______
29. Any Contagious Diseases?______
30. Is there anything else we should know? Please explain:______
______
Name: ______Date:______
31. Lifestyle:
a.Do you typically eat at least three meals per day? Y N If no, how many? ______
b.Typical Breakfast: ______
Typical Lunch: ______
Typical Dinner: ______
Are you Vegetarian? Y N Do you eat fish? Y N Eggs? Y N Dairy? Y N
c.Exercise routine: ______
d.Spiritual practice: ______
e.How is your sleep? ______How many hours per night do you sleep? ______
Do you wake up often? Y N Do you wake feeling rested? Y N
f.Level of education completed: High School Bachelors Masters Doctorate Other
g.Occupation: ______Employer: ______Hours/Week: ______Do you enjoy work? Y/N Why/Why not? ______
h.Nicotine (how much): ______
Caffeine (what & how much)______
Alcohol (howmuch):______
Drugs (what & how much): ______
Soda (how much): ______
i.Have you experienced any major traumas? Y N Explain:______
______
j.Approximately how many ounces of water do you drink per day? ______oz.
k.Television habits: ______Reading habits: ______
l.Interests and hobbies: ______
m.Energy Level: Low Medium High Does it change throughout the day? ______
n.What are your goals with our treatment?______
o. Are there things that you would like to be able to do but are unable to do right now due to your chief complaint? (ie-exercise, activities, work, family, etc.): ______
______
p. What are your top three priorities/goals for treatment?______
______
______
q. Any questions, concerns, expectations regarding your care? ______
______
______
r. If you have specific requests, conditions that you would like your practitioner know, please touch base
during your first treatment. If you have never been to an Oriental Medicine practitioner, please eat a healthy
meal before your first session.
We strive to give you the most optimal care & assist you in your health needs.
Signature: ______Date:______
Printed Name: ______Date: ______
Financial Policy & Rates:
Initial Acupuncture visit & follow ups at 90 min. $105
Follow-up acupuncture visit: 60 min. $75
Initial & follow up Fusion (Acupuncture & soft tissue techniques) visit 90 min. $120
Follow up Fusion (Acupuncture & soft tissue techniques) visit 60 min. $90
How it works…
All payments are due at the time of service.
If you have insurance that covers acupuncture we will gladly provide you with the necessary forms for you to bill your insurance so your insurance will reimburse you directly.
Please be on time, if you are late that time will be deducted from your treatment time and you will be charged the full amount. Please show up 15 minutes early to allow time to park, etc.
Most conditions require an average of 4-8 treatments, although some will respond within 2-4 visits and others may require a longer series. This depends on the severity, the chronic nature of the chief complaint and your body’s health and ability to heal itself.
We accept CASH & CHECKS ONLY.
Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment cancelled with less than 24 hours notice you may be charged the full appointment fee. Insurance will not pay for a missed appointment.
A $25 fee will be charged for all returned checks.
Please indicate your understanding and acceptance of these policies by signing below.
______
Signature ______Date ______
Printed Name ______Date______
Consent to Treatment Form
By signing below, I do hereby voluntarily consent to be treated with Chinese Medicine by a licensed acupuncturist at Yoga Pearl.
I understand that acupuncturists practicing in the state of Oregon are not primary care providers and that regular primary care by
a licensed physician is an important choice that is strongly recommended by this clinic’s practitioners.
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin at certain points in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. Moxa is the application of heat to help regulate the physiology & function of the body. I am aware thatcertain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, burning/scaring (moxa), fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.
Herbs/Vitamins & Supplements: I understand that herbal medicine as well as vitamins and supplements may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and
dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. Should I experience any problems, which I associate with these substances, I should
suspend taking them and contact the prescribing practitioner.
Acupressure/Tui-Na/Cupping/GuaSha: I understand that I may also be given one or more of these as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment at any time if it is too uncomfortable.
Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I amaware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment at any time.
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.
Signature: ______Date:
Date: ______/______/______
Printed Name: ______
Privacy Policies / HIPAA Form
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment. I consent to the use or disclosure of my identifiable health information by Uma Tupper, L.Ac., MAOM, LMT for the purposes of diagnosis, providing treatment, obtaining payment for my health care bills and to conduct health care operations. I understand that my diagnosis &/or treatment may be conditioned upon my consent as evidenced by my signature on this document. Uma reserves the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by requesting the most current notice during any office visit.
I understand that this information serves as:
1 A basis for planning my care and treatment.
2 A means of communication among the healthcare professionals who contribute to my care.
3 A source of information for applying my diagnosis and surgical information to my bill.
4 A means by which a third-party payer can verify that services billed were actually provided.
5 A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare
professionals.
I understand that I have the right:
1 To object to the use of my health information for directory purposes.
2 To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or
healthcare operations – and that the organization is not required to agree to the restrictions requested.
3 To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereupon.
I request the following restrictions to the disclosure of my health information:
Signature: ______Date:
Date:______/______/______
Printed Name: ______